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When planning for the care of the client who is dying of diagnosed cancer, one of the goals is that the client verbalizes her or his acceptance of impending death. Which client statement indicates to the nurse that this goal has been reached?
- A. I just want to live until my 100th birthday.
- B. I would like to have my family here when I die.
- C. I'll be ready to die when my children finish school.
- D. I want to go to my daughter's wedding. Then I'll be ready to die.
Correct Answer: B
Rationale: Acceptance is often characterized by plans for death. Often the client wants loved ones nearby. The remaining options all reflect the bargaining stage of coping during which the client tries to negotiate with her or his higher power or fate.
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When planning the care of the client diagnosed with thromboangiitis obliterans (Buerger's disease), the nurse incorporates information on which support service to best help the client cope with the lifestyle changes that are needed to control the disease process?
- A. Consult with a dietician
- B. Pain management clinic
- C. Smoking cessation program
- D. Referral to a medical social worker
Correct Answer: C
Rationale: Smoking is highly detrimental to the client with Buerger's disease, and clients are recommended to stop completely. Because smoking is a form of chemical dependency, referral to a smoking cessation program may be helpful for many clients. For many clients, symptoms are relieved or alleviated when smoking stops. None of the remaining options are directly related to the physiology associated with this condition.
A client is brought to the emergency department after overdosing on sleeping pills. The nurse is able to wake the client. Which question does the nurse ask first?
- A. Why did you take the medication?
- B. Can you share what is bothering you?
- C. How much medication did you take?
- D. Were you trying to kill yourself?
Correct Answer: C
Rationale: Determining the amount of medication taken is critical to assess the overdose’s severity and guide immediate treatment. Intent, emotional state, or reasons are secondary to ensuring physical safety.
When performing an assessment on a client who is suicidal, which question is the most appropriate for the nurse to ask?
- A. Do you have a death wish?'
- B. Do you wish your life was over?'
- C. Do you ever think about ending it all?'
- D. Do you have any thoughts of killing yourself?'
Correct Answer: D
Rationale: A lethality assessment requires direct communication between the client and the nurse concerning the client's intent. It is important to provide a question that is directly related to lethality. Euphemisms should be avoided.
A teenager diagnosed with celiac disease arrives at the emergency department reporting profuse, watery diarrhea after a pizza party the night before. The client states, 'I don't want to be different from my friends.' Which acute client concern should the nurse focus on when responding to the client?
- A. Diarrhea
- B. Low self-esteem
- C. Deficient fluid volume
- D. Increased inflammation
Correct Answer: B
Rationale: The client expresses concern about being different from friends. Celiac crisis is a medical diagnosis that often involves diarrhea. Although the question states that the client has profuse, watery diarrhea, no data identify an actual deficient fluid volume or increased inflammation.
The nurse overhears the supervisor reprimand the charge nurse for not discussing feelings with a client. Shortly after, a client asks the charge nurse for an extra blanket. The charge nurse angrily responds, 'Get it yourself!' The nurse recognizes the charge nurse is displaying which defense mechanism?
- A. Compensation.
- B. Displacement.
- C. Conversion.
- D. Projection.
Correct Answer: B
Rationale: Displacement involves redirecting emotions from one target to another. The charge nurse, upset from the reprimand, displaces anger onto the client by responding harshly to a simple request, rather than addressing the supervisor.